Corticosteroid therapy osteoporosis

Guidelines for managing corticosteroid-induced osteoporosis recommend measuring BMD at the beginning of chronic therapy (prednisone 5 mg or more daily or equivalent for at least 6 months) and followup monitoring with DXA in 6 to 12 months. BMD should be measured in patients taking chronic therapy whose baseline values were not obtained. 

A special problem caused by inhaled corticosteroids is the occurrence of oropharyngeal candidiasis. The risk of this complication can be reduced by having patients gargle water and spit after each inhaled treatment. Hoarseness can also result from a direct local effect of inhaled corticosteroids on the vocal cords. These agents are remarkably free of other short-term complications in adults but may increase the risks of osteoporosis and cataracts over the long term. In children, inhaled corticosteroid therapy has been shown to slow the rate of growth, but this effect appears to be transient Asthma itself delays puberty, and there is no evidence that inhaled corticosteroid therapy in childhood influences adult height. 

Sato S, Ohosone Y, Suwa A, Yasuoka H, Nojima T, Fujii T, Kuwana M, Nakamura K, Mimori T, Hirakata M. Effect of intermittent cyclical etidronate therapy on corticosteroid induced osteoporosis in Japanese patients with connective tissue disease 3 year follow up. J Rheumatol 2003 30 2673-9. 

Osteoporosis is also common in those on long-term corticosteroid therapy (for example patients with autoimmune hepatitis or coexisting inflammatory bowel disease). Patients with chronic liver disease may also have other risk factors for osteoporosis related to their disease state. These include vitamin D deficiency, excessive alcohol consumption, poor diet, physical inactivity and low body mass index. Oestrogen deficiency in the postmenopausal stage further increases the risk. 

Risedronate is approved for the therapy of Paget s disease, as well as for the therapy of both postmenopausal and corticosteroid-induced osteoporosis. 

If corticosteroid therapy is not deemed necessary to treat disease, followup examination and objective testing should be performed on a yearly basis to monitor disease progression. Because of the need for lifelong treatment, patients should be informed of the long-term side effects of corticosteroids and be monitored and treated for consequences such as hypertension, hyperglycemia, osteoporosis, and cataracts. 

Patients with IBD, particularly those with CD, are also at risk for bone loss. This may be a function of malabsorption or an effect of repeated courses of corticosteroids. Patients with IBD should receive a baseline bone density measurement prior to receiving corticosteroids. Vitamin D and calcium supplementation should be used in all patients receiving long-term corticosteroids. Oral bisphosphonate therapy may also be considered in patients receiving prolonged courses of corticosteroids or in those with osteopenia or osteoporosis. 

Side effects of inhaled corticosteroids are relatively mild and include hoarseness, sore throat, oral candidiasis, and skin bruising. Severe side effects such as adrenal suppression, osteoporosis, and cataract formation are reported less frequently than with systemic corticosteroids, but clinicians should monitor patients receiving high-dose chronic inhaled therapy. 

Spontaneous reports of osteoporosis, osteopenia, bone fractures, and delayed healing of bone fractures have been seen in the isotretinoin population. While causality to isotretinoin has not been established, an effect cannot be ruled out. Physicians should use caution when prescribing isotretinoin to patients with a genetic predisposition for age-related osteoporosis, a history of childhood osteoporosis conditions, osteomalacia, or other disorders of bone metabolism. This would include patients diagnosed with anorexia nervosa and those who are on chronic drug therapy that causes drug-induced osteoporosis/osteomalacia and/or affects vitamin D metabolism, such as systemic corticosteroids and any anticonvulsants. 

Because side effects can complicate the use of corticosteroids, a careful history and certain tests may be advisable, particularly if a patient may require prolonged ocular therapy. Steroids should be used with great caution in patients with diabetes mellitus, infectious disease, chronic renal feilure, congestive heart feilure, and systemic hypertension. Systemic administration is generally contraindicated in patients with peptic ulcer, osteoporosis, or psychoses. Topical steroids should be used with caution and only when necessary in patients with glaucoma. 

Corticosteroids Increased sensitivity to GI complications Increased risk osteoporosis Lower initial dose Minimize duration of therapy if possible... 

Owing to the increased risk of osteoporosis in the elderly, patients requiring high doses of inhaled corticosteroids should have their bone mineral density determinations followed and appropriate therapies for osteoporosis instituted if necessary. ... 

Once skeletal maiurily has been attained, it is the magnitude of the subsequent bone loss which may lead to osteoporosis. Tlie use of corticosteroid drugs should be minimized. Stopping smoking is impttrtant. At the menopause, hormone replacement iherapy is of benefit, not only for the relief of menopausal symptoms but also to prevent rapid bone loss. Indeed, cardiovascular protection also follows as an incidental benefit of such therapy. 

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